Avatrombopag

DOPTELET

What it isOral thrombopoietin-receptor agonist stimulating platelet production; chronic ITP and periprocedural thrombocytopenia in liver disease.

Why this oneUnlike eltrombopag, it has no polyvalent-cation chelation restriction and no hepatotoxicity boxed warning.

What limits itPlatelets can overshoot and cause thrombosis, including portal-vein thrombosis; monitor counts rather than chasing normalization.

FDA label

FDA dosing	Population	Start	Target	Max
Thrombocytopenia in chronic liver disease, scheduled procedure	Adults	Platelets <40 x 10^9/L: 60 mg QD x5 days; 40 to <50: 40 mg QD x5 days (begin 10-13 days pre-procedure)	5-day course only; procedure 5-8 days after last dose	60 mg QD x 5 days
Chronic immune thrombocytopenia, insufficient response to prior therapy	Adults	20 mg QD (tablets)	Lowest dose keeping platelets >=50 x 10^9/L (levels: 20 mg QW up to 40 mg QD)	40 mg/day
Persistent/chronic immune thrombocytopenia	6-17 yr (tablets)	20 mg QD	Lowest dose keeping platelets >=50 x 10^9/L	40 mg/day
Persistent/chronic immune thrombocytopenia	1 to <6 yr (Sprinkle granules)	10 mg QD	Lowest dose keeping platelets >=50 x 10^9/L	20 mg/day

Titration ITP: adjust one dose level at a time; wait 2 weeks after each change before further adjustment

Renal Undefined

Hepatic Undefined

Do not use to normalize platelet counts; stop if platelets >400 x 10^9/L (restart one level lower when <150)

Take with food
Sprinkle: open capsules and mix granules with soft food or liquid; take immediately; do not swallow capsules whole or chew/crush granules
Tablets and Sprinkle are NOT substitutable mg-for-mg (granules more bioavailable); if switching, monitor platelets weekly until stable
Missed dose: take as soon as remembered; do not double; resume usual time next day
ITP: platelets weekly until stable >=50 x 10^9/L, then monthly; weekly x4 wks after stopping
ITP with moderate/strong dual CYP2C9+CYP3A4 inhibitors: start 20 mg (peds 1-<6: 10 mg) three times weekly; with dual inducers: start 40 mg (peds 1-<6: 20 mg) QD
ITP: discontinue if platelets <50 after 4 wks at max dose, or >400 after 2 wks at lowest weekly dose

Thrombotic/thromboembolic complications (TPO-receptor agonist class): portal vein thrombosis 0.4% in CLD; arterial/venous events 7% in adult ITP
Consider thrombotic risk with inherited (Factor V Leiden, prothrombin 20210A, antithrombin/protein C or S deficiency) or acquired (antiphospholipid syndrome) risk factors
Hypersensitivity reactions reported postmarketing

CLD (>=3%): pyrexia, abdominal pain, nausea, headache, fatigue, peripheral edema; hyponatremia (serious)
Adult ITP (>=10%): headache, fatigue, contusion, epistaxis, URTI, arthralgia, gingival bleeding, petechiae, nasopharyngitis
Pediatric ITP (>=10%): viral infection, nasopharyngitis, cough, pyrexia, oropharyngeal pain

Pregnancy May cause fetal harm (animal data at exposures well above human); insufficient human data

Lactation Breastfeeding not recommended during treatment and for >=2 weeks after last dose; for short courses, pump and discard

NO BOXED WARNINGS

Principal riskNo FDA boxed warning.

Cost, est. cash$500–$20,000+/dose or month

Generic entry2028 est.

Therapeutic safety burden2 / 4

Overdose danger1 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk1 / 4

Legacy pregnancy categoryNot assigned — PLLR-era drug

Defining liabilityThrombosis and excessive platelet response are the principal serious risks.